ATI RN
Nursing Care of the Newborn Quizlet Questions
Question 1 of 5
Which assessment finding of a newborn requires prompt action by the nurse?
Correct Answer: C
Rationale: The correct answer is C: Pause in breathing lasting 20 seconds. This finding indicates a potential apnea episode in the newborn, which requires immediate attention to prevent further complications like hypoxia. The pause in breathing lasting 20 seconds exceeds the normal range for apnea in newborns, typically defined as a pause lasting more than 15 seconds. Prompt action is necessary to assess and address the underlying cause of the apnea episode. Choice A (Respiratory rate of 50 breaths per minute) is within the normal range for newborns (30-60 breaths per minute) and does not require immediate action. Choice B (Cyanosis of the extremities) may indicate poor circulation but is not as urgent as a prolonged pause in breathing. Choice D (Pause in breathing for 15 seconds followed by rapid respirations) is incorrect as it does not meet the criteria for apnea in newborns and does not require immediate action.
Question 2 of 5
An infant at term was born at 0105 hours. The nurse is developing a plan of care for the newborn. During which time range will the nurse plan on performing the assessment to determine a Ballard score?
Correct Answer: B
Rationale: The correct answer is B (0200 to 0600) because the Ballard score is typically assessed within the first 12-24 hours of life. Given that the infant was born at 0105 hours, the nurse should plan on performing the assessment between 0200 to 0600. This time frame falls within the recommended window for assessing the Ballard score accurately. Choices A, C, and D are incorrect because they fall outside the optimal time range for conducting the assessment. Option A (0115 to 0130) is too soon after birth, and options C (1400 to 1800) and D (2000 to 2300) are too late for the initial assessment as per standard practice.
Question 3 of 5
The labor and delivery nurse understands that some neonates spontaneously take a breath once the head and chest is delivered. Which understanding does the nurse have for the neonate that requires chemical stimuli to breathe?
Correct Answer: C
Rationale: Step 1: Mild hypoxia and decreased pH stimulate the brain to initiate breathing in neonates. Step 2: This chemical stimuli trigger the respiratory centers in the brainstem. Step 3: Oxygen administration may not be necessary as the neonate's own respiratory drive is initiated by chemical stimuli. Step 4: Carbon dioxide administration is not needed as high levels can be harmful. Step 5: Suctioning is not used to stimulate breathing but to clear airways if necessary. Summary: Choice C is correct as it aligns with the physiological response of neonates to chemical stimuli for breathing, while the other choices are not relevant or could be potentially harmful.
Question 4 of 5
The nurse works in a postnatal nursery and is required by hospital policy to perform a gestational age assessment on specified neonates. On which neonate is the nurse most likely to perform this assessment?
Correct Answer: A
Rationale: The correct answer is A: The neonate with a birth weight of 4,100 g. Gestational age assessment is typically done based on birth weight, as it is a more accurate indicator than other factors like labor duration or exposure to medications. A birth weight of 4,100 g is considered to be indicative of a full-term baby, which is usually around 37-42 weeks gestation. Other choices like B (neonate born at 37 weeks) could be a premature or post-term baby, C (born after 18-hour labor) doesn't directly indicate gestational age, and D (exposed to oxytocin) is not a reliable indicator of gestational age. Weight is a key factor in determining gestational age, making choice A the most appropriate for the nurse to perform the assessment.
Question 5 of 5
The nurse in the neonate nursery notices a neonate, born 45 minutes ago, is unresponsive to external stimuli, and has a respiratory and heart rate below normal range. Which action does the nurse take?
Correct Answer: B
Rationale: The correct answer is B because newborns typically go through a period of deep sleep immediately after birth. This state is characterized by decreased responsiveness to external stimuli and lower respiratory and heart rates. It is important for the nurse to allow the neonate to naturally continue deep sleep as this is a normal physiological process. Picking up the neonate (choice A) may disrupt this important sleep state. Asking another nurse for assistance (choice C) may not be necessary at this point as the neonate's condition is likely normal. Notifying the caregiver (choice D) may cause unnecessary alarm as the neonate is most likely exhibiting normal behavior for this stage.